8
University
Center
for
Academic
and
Workforce
Development
SCHENECTADY
SUNV
UCAWD
SCHENECTADY COLLEGE & CAREER OUTREACH CENTER (SCCOC)
APPLICATION FOR ADMISSION
IN ADDITION TO THE INFORMATION IN THIS FORM, YOU WILL NEED TO PROVIDE PROOF OF RESIDENCY, EDUCATIONAL
BACKGROUND, AND INCOME IN ORDER TO RECEIVE SERVICES
IDENTIFICATION INFORMATION
Date: SSN: DOB:
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.) (Previous Last Name)
Mailing Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Alternate (Permanent) Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Home Phone: ( ) Cell Phone: ( )
Email Address:
PARENT / GUARDIAN INFORMATION
If you are under 21 years of age and do not reside with a parent or legal guardian, please provide the
following information for a parent or legal guardian.
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.)
Mailing Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Home Phone: ( ) Cell Phone: ( )
EMERGENCY CONTACT INFORMATION
Please provide contact information for an emergency contact.
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.)
Phone: ( ) Relationship:
BIOGRAPHIC INFORMATION
Gender: ( ) Male ( ) Female Marital Status: ( ) Unmarried ( ) Married
SCCOC APPLICATION FOR ADMISSION PAGE 1
